Author Insights: Excessive Workloads for Hospitalists Are Common and Put Patients at Risk

Henry J. Michtalik, MD, MPH, MHS, of Johns Hopkins University in Baltimore, and colleagues found that many hospital physicians report having unsafe workloads that jeopardize the quality of care. Image: Henry J. Michtalik

Patient care may be suffering at many hospitals because hospital physicians are often overloaded, suggest results from a survey published today in JAMA Internal Medicine.

Concerns that clinicians at hospitals were stretched thin by excessive caseloads or fatigue led to restrictions on resident physician work hours; in some states, regulations intended to ensure nurse staffing at levels that optimize patient safety were enacted. Such efforts may have the unintended consequence of increasing the workload of attending physicians at hospitals, but there has been limited research on this and how it affects patient care and safety.

To provide some data on hospitalist workload, a research team from Johns Hopkins University in Baltimore surveyed a national sample of 890 physicians participating in QuantiaMD.com, an online community for physicians, and 57% of them responded. When asked how often their caseload exceeded safe levels during weekday hours, 40% of the respondents reported an unsafe workload at least once a month and 36% reported they had an excessive workload weekly. A quarter of the respondents reported that such overloads prevented them from fully discussing treatment options with patients. More than 1 in 5 reported that their workload likely contributed to patient transfers, patient complications, or death.

Henry J. Michtalik, MD, MPH, MHS, lead author of the study, discussed the findings with news@JAMA.

news@JAMA: Why did you choose to survey physicians participating in an online community?

Dr Michtalik: We needed a sample of physicians who practice in different environments. Hospitalists are increasingly prevalent at hospitals, but there is no specific licensure for hospitalists, so there isn’t a national database. So we chose an online community that has a broad representation.

news@JAMA: The average age of your respondents was 38. Is this representative of the field, or did you capture a slice of younger hospitalists?

Dr Michtalik: We consulted the Society of Hospital Medicine and compared our information to their national survey. The hospitalist profession as a whole is younger than our internal medicine colleagues.

news@JAMA: Were you surprised that so many physicians report excess workloads?

Dr Michtalik: We know that attending physicians are working with other clinicians who have guidelines limiting their workloads. We know there has been increased access to health care with the Affordable Care Act, and with it an increasing flow of patients. With restrictions on other providers, the workload is going somewhere.

We were surprised at the numbers, especially because we excluded nights, weekends, holidays, and cross-coverage. We asked about standard daytime shifts. At other times, we expect that patient care is less active so providers are able to care for additional patients. For example, there is less testing and fewer procedures done during the evening or weekends.

news@JAMA: How does such overload affect patient care?

Dr Michtalik: One of the biggest impacts of excess workload was on discussions with patients. Under these workloads, physicians have to prioritize what gets done. We found that 1 in 4 hospitalists reported not being able to fully discuss treatment options or answer patient questions. [About 22% of physicians responding to the survey] also reported ordering tests or consults because they lacked adequate time to evaluate the patient themselves.

news@JAMA: How does cost of care factor into this issue?

Dr Michtalik: One of main mechanisms for controlling health care costs has been reducing reimbursement to increase efficiency of care at hospitals. While this may increase efficiency in terms of how many patients clinicians can see, it may have unintended consequences. For example, 1 in 4 physicians are reporting they are ordering unnecessary tests because they don’t have time to evaluate patients. We may be being penny-wise by increasing patients per clinicians but pound-costly by increasing the costs of downstream care, such as tests and consults.

news@JAMA: What are the next steps for this area of research?

Dr Michtalik: This survey is the first step in assessing how hospitalist workload is impacting care. We recognize every physician and hospital system is different. The team structures are different. Some involve nurse practitioners or residents; sometimes a physician is alone. One of the areas we will continue to explore is understanding what are the physician and team factors that predict unsafe workloads.

news@JAMA: What can be done to reduce hospitalist overload and improve care?

Dr Michtalik: We have to look at the modifiable and notifiable factors affecting patient care. Sometimes the patient population may be more acute and complex, for example. That type of factor is less modifiable. But we do know that geographically locating a physician’s patients in 1 unit may increase efficiency. We also need to look at what modifiable factors are different in hospitals that are having unsafe hospitalist workloads compared with those that are not and learn from our colleagues who are not having unsafe workloads.

Hopefully, this study begins a discussion about attending physicians’ workload and how to balance hospitalist workload with patient safety and quality of care.